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Cardiology and Respiratory SA Med > Stenotic Diseases > Flashcards

Stenotic Diseases Flashcards

1
Q

Definition of stenosis

A
  • Narrowing in the outflow tract
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2
Q

What type of hypertrophy occurs secondary to stenosis?

A
  • Pressure overload, so it’s a concentric hypertrophy
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3
Q

What are the two types of pulmonic stenosis?

A
  • Dysplastic

- Hypoplastic

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4
Q

Which is preferred for type of stenosis: dysplastic or hypoplastic?

A
  • Dysplastic
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5
Q

What occurs in dysplastic stenosis?

A
  • Fused valve, so it only opens a very small hole
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6
Q

What occurs in hypoplastic stenosis?

A
  • Too narrow to begin with
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7
Q

Who gets pulmonic stenosis?

A
  • Small breeds
  • TERRIERS (pitbulls)
  • Brachiocephalic dogs
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8
Q

Where is the PMI for the murmur in PS?

A
  • Left heart base
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9
Q

Timing of the murmur for PS?

A
  • Systolic
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10
Q

Quality of the murmur for PS?

A
  • Ejection type murmur (crescendo-decrescendo
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11
Q

Additional murmur that can happen with PS if progresses?

A
  • Tricuspid regurgitation
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12
Q

What is the PMI, timing, and quality of a tricuspid regurgitation murmur that occurs secondary to pulmonic stenosis?

A
  • PMI (right apex) = tricuspid
  • Timing is systolic
  • Quality is regurgitant/plateau/band
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13
Q

Pulmonic stenosis femoral pulse quality

A
  • Normal

- May have pulse deficits

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14
Q

Can you have jugular pulses with PS?

A
  • Yes, you can
  • Possible to have jugular distention and pulses
  • Will not always be present
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15
Q

Arrhythmias with pulmonic stenosis - are they possible?

A
  • Yes

- Can cause pulse deficits

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16
Q

Other physical exam findings with PS?

A
  • May have ascites secondary to right heart failure
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17
Q

Appearance of radiograph for a dog with pulmonic stenosis?

A
  • Main pulmonary artery will be enlarged due to post-stenotic dilatation
  • Right atrial enlargement
  • Right ventricular enlargement
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18
Q

Appearance of pulmonic stenosis on echocardiogram

A
  • Concentric hypertrophy of the right ventricle
  • Right ventricular free will can be much larger than the left ventricular lumen
  • Pulmonic valve will be small
  • Can see a post-stenotic dilatation
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19
Q

What determines severity of pulmonic stenosis?

A
  • How wide does it open?
  • If it opens just a tiny bit, that’s very severe
  • Creates more extra pressure
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20
Q

How do you determine how much pressure is on the right heart secondary to pulmonic stenosis?

A
  • Pressure ~= velocity
  • Can use the modified Bernoulli equation
  • ∆P = 4v^2
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21
Q

Make sure you can go through the calculations for the right ventricle based on the velocity of flow through the stenotic valve

A

just make sure you can do it

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22
Q

Normal pulmonary artery pressure

A
  • 20
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23
Q

Normal right ventricular pressure

A
  • 20 during systole

- 5 during diastole

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24
Q

What is considered mild pulmonic stenosis PA velocity and RV-PA gradient?

A

PA velocity: 2.5-3.5 m/s

Gradient: 30-50 mmHg

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25
Q

What is considered moderate pulmonic stenosis PA velocity and RV-PA gradient?

A

PA velocity: 3.5-4.5 m/s

Gradient: 50-80 mmHg

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26
Q

What is considered severe pulmonic stenosis PA velocity and RV-PA gradient?

A

PA velocity: >4.5 m/s

Gradient: >80 mm Hg

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27
Q

What is the treatment of choice for most cases of pulmonic stenosis?

A
  • Balloon valvuloplasty
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28
Q

Balloon valvuloplasty procedure details

A
  • Catheter in the jugular vein
  • Insert it into the heart at the level of the pulmonic valve
  • Trying to measure the annulus size
  • Can see a little filling defect
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29
Q

What size balloon do you pick?

A
  • should be 1.5x the size of the annulus
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30
Q

What will cardiac output be as the balloon is inflated?

A
  • Crappy
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31
Q

What can happen to the rhythm of the heart as you inflate the balloon?

A
  • Often can go into V-tach
32
Q

Success rate of balloon valvuloplasty?

A
  • 70% success rate
33
Q

What is considered a “procedural success” for balloon valvuloplasty?

A
  • 50-60% reduction in gradient
  • NOT CURATIVE
  • Palliative, and depends on the degree of severity that the dog comes in with
34
Q

Re-stenosis rate after balloon valvuloplasty?

A
  • About 15-20% of dogs will re-stenose, which can occur at any time
35
Q

What can make a candidate less ideal for balloon valvuloplasty?

A
  • Sub- or supra-valvular stenosis

- Pulmonary annular hypoplasia (if the artery is tiny to begin with :()

36
Q

Medical management of pulmonic stenosis

A
  • Treatment of diastolic dysfunction with Beta blockers
  • Treatment of arrhythmia if present
  • Treatment of CHF if present
37
Q

What is the purpose of beta blockers with diastolic dysfunction?

A
  • Slow heart rate
  • Promotes right ventricular filling and perfusion
  • Decreased contraction against obstruction
38
Q

What can occur secondary to concentric hypertrophy if severe?

A
  • Myocardial ischemia

- Can result in some arrhythmias or death

39
Q

How to treat CHF for PS?

A
  • Furosemide and an ACE inhibitor

- +/- abdominocentesis (remember that it is right sided heart failure)

40
Q

Anomalous left coronary artery

A
  • Can occur with pulmonic stenosis
  • Basically, some animals never have a left coronary artery and get abnormal growth of it
  • Unpredictable location, so these are at greater risk
41
Q

Who is at risk for an anomalous left coronary artery?

A
  • English bulldogs, French bulldogs, boxers
42
Q

What is a risk that can occur with an anomalous left coronary artery?

A
  • Balloon valvuloplasty may rupture coronary artery

-

43
Q

Prognosis for PS

A
  • Depends on severity of disease
44
Q

Prognosis for mild to moderate PS

A
  • May live normal lives
45
Q

Prognosis for severe PS without treatment

A
  • 3 years
46
Q

Prognosis for severe PS with treatment

A
  • Depends on post-balloon gradient
47
Q

What can worsen the prognosis for severe PS?

A
  • Congestive heart failure
  • Arrhythmias (sudden death!)
  • Concurrent congenital heart diseases
48
Q

What happens in subaortic stenosis?

A
  • The valve is normal, but there is a narrowing below it
49
Q

Who gets subaortic stenosis?

A
  • Golden retrievers, large breeds, Newfoundlands, Rottweilers, Boxers, German Shepherd dogs
50
Q

Point of maximal intensity, timing, and quality of SAS murmur?

A
  • Left heart base
  • Systolic
  • Ejection quality murmur
51
Q

Radiation murmur with subaortic stenosis

A
  • Can occur due to radiation to the carotid arteries

- Listen to the thoracic inlet

52
Q

What are your top two differentials for a left heart base murmur?

A
  • Sounds similar to pulmonic stenosis

- Differentiate by looking at the breed and exam findings

53
Q

What additional murmur can occur with SAS?

A
  • Aortic regurgitation
54
Q

Aortic regurgitation murmur PM, quality, and timing?

A
  • Left heart base
  • Diastolic
  • Decrescendo murmur
55
Q

Femoral pulse quality with SAS

A
  • Normal to weak and late
56
Q

Jugular distensions or pulses with SAS

A
  • SHould be none
57
Q

Arrythmias with SAS

A
  • Pulse deficits

- Definitely possible

58
Q

Radiographic findings with SAS

A
  • Left auricular bulge
  • Thoracic aorta has a bulge
  • Bulge in the left atrium
  • Backpack in left atrium on the lateral view
59
Q

What type of hypertrophy occurs with SAS?

A
  • Concentric hypertrophy
60
Q

Echocardiogram findings with SAS

A
  • Mushroom
  • Interventricular septum will be thickened
  • Left atrium narrower
  • Dilation in the region below the aortic valve
  • Blood flow will be really fast below the valve
61
Q

How to determine severity of the subaortic stenosis?

A
  • Again, has to do with the modified Bernoulli equation
  • ∆P = 4v^2
  • Aortic flow = 5 m/s
62
Q

Normal aortic pressures

A
  • Systole: 120

Diastole: 80

63
Q

Normal left ventricular pressures

A

Systole: 120
Diastole: 6

64
Q

Ao velocity and LV-Ao gradient for mild disease

A

Ao velocity: 2.5-3.5 m/s

LV-Ao gradient: 30-50 mmHg

65
Q

Ao velocity and LV-Ao gradient for moderate disease

A

Ao velocity: 3.5-4.5 m/s

LV-Ao gradient: 50-80 mmHg

66
Q

Ao velocity and LV-Ao gradient for severe disease

A

Ao velocity: >4.5 m/s

LV-Ao gradient: >80 mmHg

67
Q

Treatment for SAS: Surgical

A
  • Not effective

- Fibromuscular ridge below the valve rather than a problem with the valve itself

68
Q

Medical management of SAS

A
  • Treat diastolic dysfunction
  • Treat arrhythmias if present**
  • Treat left-sided CHF if present
69
Q

How to treat diastolic dysfunction?

A
  • Beta-blockers
70
Q

What function do beta-blockers have for SAS treatment?

A
  • Slows HR
  • Promotes LV filling and perfusion
  • Decrease contraction against an obstruction
71
Q

How to treat left sided heart failure if present in SAS?

A
  • Furosemide

- ACE inhibitors

72
Q

What are animals with SAS at increased risk for?

A
  • Endocarditis
73
Q

What should you do for patients with SAS considering the disease they are at increased risk for?

A
  • Aggressive treatment of infections

- Perioperative antibiotics for procedures that cause bacteremia

74
Q

Prognosis for mild SAS

A
  • Probably live a normal life
75
Q

Prognosis for moderate to severe SAS

A
  • ~2-4 years
76
Q

What will worsen prognosis of moderate to severe SAS?

A
  • CHF
  • Concurrent congenital heart diseases
  • Endocarditis
  • Arrhythmias - SUDDEN DEATH!
77
Q

What can occur because of the concentric hypertrophy with SAS?

A
  • Ischemic injury
  • Oxygen starved heart
  • Can get VPCs, Ventricular tachycardia, and SYNCOPE or sudden death

Cardiology and Respiratory SA Med (15 decks)

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